barriers to primary care access in rural medically

Online Journal of Rural Nursing and Health Care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582

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Barriers to Primary Care Access in Rural Medically Underserved Areas

Suzanne Hewitt, DNP, APRN, FNP-C 1

Susan McNiesh, PhD, MS, RNC-OB 2

Lilo Fink, DNP, FNP-BC 3

1 Consortium Doctor of Nursing Practice Program, California State University Northern

California, [email protected]

2 Professor Emerita, The Valley Foundation School of Nursing, San Jose State University.

[email protected]

3 Part Time Faculty, Doctoral Program School of Nursing, Walden University,

[email protected]

Abstract

Purpose: To explore patients’ perceptions of factors that combine to limit or prevent access to

primary care in rural medically underserved areas or populations (MUAPs ).

Sample: Two focus group sessions were conducted with a sample of eight rural community

members. Participants were identified as having had a minor illness or injury in the previous six

months and having been unable to access their primary care provider (PCP) for care.

Method: This qualitative study used data generated from comments shared by participants of the

focus groups in response to a series of open-ended questions designed to promote meaningful

dialogue. The sessions were audiotaped and transcribed by a professional transcription service.

The transcribed data was then analyzed by the authors using qualitative content analysis methods


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to classify the data into themes.

Findings: Analysis of data generated from the focus groups identified three dominant themes:

People living in rural MUAPs have unique health care needs when compared to residents of urban

or metropolitan areas; rural community members perceive an inability to access their PCP for

sudden or unexpected illness or injury leading to foregone care, delayed care or seeking care in the

emergency department for nonurgent problems; and the same-day, walk-in, immediate care model

is meeting the needs of these patients.

Conclusion: The 20% of the U.S. population living in rural areas who are being cared for by only

10% of the nation’s primary care providers often lack access to safe, timely, effective, efficient,

equitable, and patient-centered health care. Implementation of care models similar to the

immediate care model in this study may offer rural community members prompt, competent,

evidence-based treatment from a nurse practitioner in a timely manner.

Keywords: rural, healthcare, access, barriers, immediate care, nurse practitioner, APRN

Barriers to Primary Care Access in Rural Medically Underserved Areas

Persons living in rural, medically underserved areas (MUAs) throughout the United States

experience more barriers to accessing healthcare than their urban counterparts (Rural Health

Information Hub [RHIhub], n.d.a.). Nationally, 20% of the population lives in rural areas but only

10% of physicians practice in rural areas (Hospitals & Health Networks, 2016). Vulnerable

populations, including persons living in designated primary care shortage areas, often lack access

to safe, effective, timely, equitable, and patient-centered care (Mareno, 2016). As more patients

have become insured under the Affordable Care Act (ACA), providers and health professionals

are required to see more patients with less time allotted for the encounter (U.S. Health Policy


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Gateway, n.d.). Factors that contribute to the shortage of healthcare providers include: (a) the

retirement of practicing providers, (b) inability or unwillingness to accept new patients by aging

providers seeking to reduce their workload, (c) difficulty in recruiting and retaining new providers

to rural areas, and (d) the fact that fewer medical students are pursuing family practice careers,

leaving a smaller pool of physicians to serve in rural areas (Ewing & Hinkley, 2013).

The Institute of Medicine published a framework for assessment of quality in health care in

2001, which lists six domains for quality measurement. The six domains of health care quality are

known by the acronym STEEEP: safe, timely, effective, efficient, equitable, and patient-centered

(Agency for Healthcare Research and Quality [AHRQ], n.d.). Persons in rural, medically

underserved areas are frequently unable to access health care in a timely or efficient manner, and

may be utilizing the emergency department (ED) inappropriately, which is not equitable, or

foregoing care, which is not safe or effective. Additionally, these community members often

forego routine preventative exams and screening for preventable or treatable conditions. Leight

(2003) applied the Vulnerable Populations Conceptual model (VPCM) to rural health and noted

that patients who are unable to access necessary health care are vulnerable to higher rates of

chronic illness and disability and higher morbidity rates because of delayed diagnoses and

increased illness (Leight, 2003). Flaskerud, who along with Winslow first described the VPCM,

noted in 1999 that “research has shown that lack of resources, rather than the presence of risk

factors, is the best predictor of illness and premature death in vulnerable populations” (Nyamathi,

Koniak-Griffin, & Greengold, 2007, p. 6). Compared to urban areas, rural areas have higher age-

adjusted rates of death from the five leading causes of death in the United States: heart disease,

cancer, unintentional injury, chronic lower respiratory disease, and cerebrovascular accident or

stroke (Moy et al., 2017).


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Literature Review

Previous studies of perceived barriers to health care access have been conducted through

mail surveys and telephonic follow up and have been largely quantitative. A 2017 study by Allen,

Call, Beebe, McAlpine, and Johnson, with a sample size of 2,194, looked at barriers to health care

among adults with Medicaid insurance in the state of Minnesota and identified barriers as either

patient-related, provider-related, or system-related. Patient-related factors included family or work

issues and unavailability of childcare. Provider-related factors included perceived discrimination

based on sex, race, ethnicity, nationality, ability to pay, or enrollment in a public health care

program. Providers who did not speak the language, understand the culture or understand the

religious beliefs of the patient were seen as barriers at this level, as were providers who were not

perceived as trustworthy or having a welcoming office. Coverage barriers, financial barriers, and

access barriers were all identified as system-level factors: lack of knowledge about services

covered by the health plan, worrying about the cost of services or medications, inability to get an

appointment, inconvenient office hours, problems with transportation, and inability to see the

provider of choice. This study also identified three negative outcomes as a result of barriers to

accessing health care in this population: (a) delayed care, (b) foregone care, and (c) no preventative

care in the past year.

A second quantitative study, published in 2015 by Hefner, Wexler, and McAlearney, used

questionnaires administered to a non-random convenience sample of 859 patients who had sought

care for non-urgent complaints at one of two urban emergency departments (EDs). Access was

examined using the Aday and Andersen framework. The researchers concluded that uninsured

patients cited income and transportation as the greatest barriers while insured patients reported

primary care infrastructure barriers such as waiting times and difficulty being seen during business


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hours due to employment. An unexpected finding of the study was that 25% of insured

respondents felt that they had no barriers to receiving health care in a primary care office, although

they were still utilizing the ED for non-urgent complaints.

Mortensen’s 2014 quantitative study of 2,733 Medicaid enrollees analyzed the relationship

between access to providers and ED utilization and found that age, sex, race or ethnicity, marital

status, education and employment status were not predictive of ED utilization but that poor health

status, chronic conditions, and the presence of disability were associated with more frequent ED

visits. The data showed a correlation between perceived ability to access primary care and the

number of ED visits by enrollees. The study reinforces the findings of the later study by Hefner

et al. (2015) that Medicaid enrollees who are unable to readily access primary care will seek care

in the ED.

Few recent qualitative studies using focus groups to generate data on patients’ perceptions

of barriers to primary health care access have been published. One very recent study used focus

groups to examine the perceptions of 15 socio-economically disadvantaged persons over the age

of 65 living in rural England. This study interpreted data in terms of a social contract that the focus

group participants expected their practitioners to honor: If the patient didn’t “bother” the provider

with minor issues, he or she expected to be accommodated promptly when they needed to be seen

for an unplanned illness or malady. Patients considered their contract to be breached when they

were unable to be seen for episodic illnesses, using the words “unwelcome”, “nuisance,” and “not

worth anything” to describe their feelings of marginalization. These focus group participants

specifically cited difficulty in getting through on the phone to make an appointment, unfavorable

interactions with receptionists, and a lack of available appointments as the greatest barriers to

access (Ford et al., 2018).


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Thus, a number of quantitative studies exploring barriers to health care in rural areas were

found with the majority of the studies looking specifically at elderly populations. There was only

one review article, Douthit, Kiv, Dwolatzky, and Biswas (2016) that examined barriers to health

care in rural populations before and after passage of the ACA. In our review of the literature, there

were no recent qualitative studies conducted in the U.S.

Purpose of the Study

An evidence-based, qualitative study was designed to increase understanding of the factors

that, according to patients’ perceptions, combine to limit or prevent access to primary care in one

rural MUA in northern California. The question that this qualitative study proposed to answer was

“How do patients living in rural, medically underserved areas perceive their ability to access

primary care services within their community?” The purpose of the study was to examine

perceived access to primary care through data generated from two patient focus groups, and to

propose practical solutions to perceived barriers. The study sought to generate data on how

patients saw their ability to access primary healthcare, what they perceived as barriers to their

ability to access health care, and what they perceived as possible solutions to these barriers.

Further, the researchers aimed to utilize the data generated to form the basis for a model of care

that can be presented to health care professionals and administrators with the purpose of facilitating

access to primary healthcare in this and other similar rural communities.

Methodology

This study used qualitative and quantitative methods of research. Focus group sessions were

conducted to gather qualitative data identifying barriers to healthcare access as perceived by

community members. A retrospective review of 1,868 Immediate Care patient charts was made

to extract data on patient insurance type and patient provider type.


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Sample

This evidence-based qualitative research study used data generated through focus group

sessions to identify problems with current processes for procuring care in the event of unexpected

illness or injury among members of a rural northern California community. Purposive, or

purposeful, sampling was utilized to identify those patients who live in the community (as opposed

to tourists) and had used a walk-in immediate care clinic within the previous six months for minor

medical complaints or injuries that were within the common realm of primary care. Examples of

chief complaints included respiratory infections, influenza, ear infections, urinary tract infections,

abscess and cellulitis, sprains and strains, and minor wounds.

Twenty-four community members were invited, by e-mail, to participate in the focus groups:

Twelve responded that they would participate, four cancelled on the day(s) of the sessions, and

eight participated. The study was approved by the California State University (CSU) Fresno

School of Nursing Institution Review Board (IRB, Protocol number DNP 1825). Permission to

conduct the study was granted in a letter of approval from the participating institution, which has

no IRB, deferred to the review and approval by CSU.

The two focus groups were composed of eight participants: five females and three males.

One participant was in the 30-44 years age group and the remaining participants were age 65 or

older. One group member had private insurance while the remainder were insured through either

Medi-Cal or Medicare. All but one participant were retired or unemployed; five were unmarried

whereas three were either married or in a domestic relationship, and all participants identified their

race as being white or Caucasian. All participants had used the immediate care clinic at least once

in the preceding six-month period.


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Risks associated with the subject’s participation in the study were those inherent in any focus

group session: There is always the possibility that a participant will know, or know of, a fellow

group member. Participants were advised that if they felt the least bit uncomfortable, the

participant could join another group at another time or withdraw from the study. An agreement

was made, verbally and in the consent form, that group members would not share information with

outsiders or talk between each other. Any opinions given or suggestions made during the group

sessions that were used in the final project remained anonymous and personal information was not

published.

Setting for Study

The Centers for Disease Control and Prevention (CDC), National Center for Health Statistics

(NCHS) classifies populations into metropolitan (urban) and nonmetropolitan (rural) categories to

better monitor the health of urban and rural residents (CDC, NCVS, n.d.). Metropolitan, or urban,

areas are further categorized as: (a) large central metropolitan areas with populations of 1 million

or more, (b) medium metropolitan areas with populations of 250,000-999,999, and (c) small

metropolitan areas, small towns or suburbs with populations of 50,000-249,000. Nonmetropolitan,

or rural, areas include: (a) micropolitan areas, rural counties where there may be a small urban

cluster of 10.000-49,999 residents; and (b) noncore areas, counties that did not qualify as

micropolitan areas. The county where the study took place is classified as a micropolitan area

(Hing & Hsiao, 2014 ).

All of the county in northern California where the study was conducted has been designated

a medically underserved population (RHIhub, n.d.b.). The county covers nearly 4000 square miles

(Zip-codes.com, n.d.) with a reported 159 providers for a population of 87,497 or a provider-to-

population ratio of 1:550. There are three hospitals in the county. The specific area of the county


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where this study was conducted was within the primary service area for a 25-bed rural district

hospital with critical access status.

Focus group sessions.

The focus group sessions followed a written guideline so that content of the sessions would

flow in a similar pattern. The sessions began with a statement of the purpose and goals of the

focus group sessions and a brief overview of the project goals. This content was followed by an

overview of confidentiality expectations, consent form signatures, and assignment of identifying

numbers to members. A number of open-ended questions were asked to move the conversation in

a direction that was designed to promote meaningful dialogue. The opening question asked the

participant what they would do if they had a minor medical complaint or injury. From there, the

conversation was steered toward ease of making appointments, frequency of routine healthcare

screening, delayed or foregone care, the need for specialty consults, utilization of the emergency

department for non-urgent care, personal barriers to access, barriers related to individual providers

or clinics, and systems barriers.

Transcriptions and analysis.

Once a paid professional transcriptionist transcribed the data from the recorded sessions, the

primary researcher, her chairperson, and her committee members used a qualitative content

analysis technique to analyze the content. Qualitative content analysis requires review of the

transcripts, examining the language within the content of the transcripts, and classifying the data

into themes relevant to understanding the phenomena being studied (Hsieh & Shannon, 2005).

Qualitative content analysis can be utilized through one of three possible approaches:

conventional, directed, or summative. The conventional approach was used for this study as it


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allows for data collection through open-ended questions, or probes, to develop categories, or

themes, derived from actual data (Hsieh & Shannon, 2005).

Results

The results of the retrospective chart reviews, combined with the responses of the focus

group participants, yielded three relevant concepts. First, patients with minor illnesses or injuries

are choosing to visit the immediate care clinic when they are unable to see their own PCP. Second,

patients are visiting this clinic whether they are publicly insured, privately insured, or uninsured.

And third, patients are visiting the immediate care clinic regardless of whether they have a primary

care provider or not. The logical interpretation of these findings is that immediate care is a viable

solution to the problem of foregone care, delayed care, and ED utilization for non-urgent problems.

During the six-month period from August 1, 2018 through January 31, 2019, a total of 1868

patients were seen in the immediate care clinic between the hours of 9:00 a.m. and 6:00 p.m.,

Monday through Friday. IBM SPSS was used to run frequencies analyses of two demographic

variables collected from these 1868 patient encounters. The first variable analyzed was insurance

type: Medicare, Medi-Cal, Blue Cross, Blue Shield, commercial, government payer, or uninsured.

The largest number of patients, over 44%, were covered by Medicare or Medicare Managed Care.

The next largest group, at 30%, was Blue Cross or Blue Shield followed by Medi-Cal and Medi-

Cal Managed Care at 14%. Six percent of patients were uninsured and six percent were covered

by commercial or government payers.

The second variable analyzed the provider types. Nearly half of the patients seen in the

immediate care clinic over this six-month period, almost 48%, reported seeing one of the seven

PCPs (four physicians, two nurse practitioners, and one physician assistant) who practice in the

same rural health clinic where this immediate care practice is located for their primary healthcare.


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Nineteen percent were regular patients at one of the other two rural health clinics in the area. All

three rural healthcare clinics are located within a quarter-mile of the area’s only hospital. Just over

17% of patients reported having no PCP. Eight percent of patients using the services at the

immediate care clinic were established with one of the area’s five providers who are in private

practice (three physicians and two nurse practitioners) and the remaining eight percent of patients

had providers who were outside the local geographical area.

Analysis of the transcribed focus group sessions identified three themes. The most

prominent theme was that people living in rural areas or communities have unique health care

needs when compared to residents of urban or metropolitan areas. A second theme identified a

perceived inability by community members to access care through their primary care providers

(PCPs) for sudden, or unexpected, episodic illness or injury and that the inability to access care

leads to foregone care, delayed care, or seeking care in the emergency department for non-urgent

problems. The third theme, unexpected at the inception of this project, emerged during the focus

group sessions and indicated that the same-day walk-in services provided at a local immediate care

clinic were meeting the needs of patients who would otherwise have foregone care, delayed care,

or sought care in the emergency department for a non-urgent problem.

Patients want to be Seen as Whole and Unique Individuals

Focus group participants described several encounters with providers wherein they did not

feel that their unique needs were addressed. One participant stated that he and his wife have had

issues with some of the providers which necessitated transferring care to a new provider while

another participant expressed “disgust” with a provider who “hardly looked at me, I mean literally

looking at the computer instead. Didn’t touch me. And I felt like a waste of time.” Participants

in the focus groups interpreted time spent on the computer as time not spent on their care: A third


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group member, noting that the provider spent time on the computer that should have been spent

focusing on the patient, suggested the use of an audio-recorder with translation by a scribe.

Another group member stated that when her regular PCP became ill and cancelled two

appointments, she “finally did get an appointment, it was one of the visiting or rent-a-docs, I call

it, and he was terrible. He saw me for 15 minutes exactly, all he did was listen to my heart, he

didn’t have my lab work, and he didn’t know anything about me.” This particular patient identified

three areas of concern in her statement: the length of time the provider spent with her, the brevity

of the physical exam, and the fact that the provider did not appear to know her past medical history

including most recent lab results. She also stated that she was so disappointed that she changed

from her regular PCP at the hospital clinic to another provider in private practice. She also stated

that she took this matter to the hospital board.

All eight focus group members verbalized concern over the shrinking pool of available local

providers and acknowledged that there are challenges in recruiting and retaining quality healthcare

providers to the area. They also expressed dissatisfaction with the practice of staffing clinics with

locums, or temporary healthcare providers. The participant who rated her care from a locum

provider as “terrible” went on to say, “It’s not as if they’ve been here a long time and they’re going

to stay. So I think that has a great effect on the way they treat patients. They’re just passing

through: I felt totally disrespected. I’m in my 80’s, so I have a few problems and he didn’t deal

with even one of them”. This comment is rich in information. It is the perception of the patient

that temporary health care providers don’t feel the same connection to, or respect for, the

community that a more permanent provider may have. This participant also acknowledges that

her age and additional health problems are a real concern.


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Community Members Perceive Significant Barriers to Primary Care Access

Members of both focus groups, all of whom reported having a regular PCP, were next asked

to share their experiences in attempting to make an appointment for an unexpected illness or injury

with their PCP. One participant stated “I wouldn’t even bother calling (my PCP) …you call your

provider and they tell you that you’re maybe going to see them in two to three weeks, if you’re

lucky.” This participant, however, also admitted that he has had some success putting himself on

the cancellation list and being seen within 24 hours. Other group members did not have experience

with the cancellation list. “I normally don’t call a provider for anything other than something I

know I can wait two weeks for an appointment.” A third respondent stated that if she needed to

be seen “quickly” (which she quantified as being seen in the next week or two), she would not be

able to see her regular PCP and would have to see another provider. A fourth group member

related being very sick with bronchitis, having trouble breathing and wheezing, and being told she

could be seen in a “couple of weeks.” She advised the scheduler that she needed to be seen “now”

and “somehow or other they arranged something.”

Participants were asked if they could give an example of any time that they, or someone they

knew, had a significant delay in receiving medical care or had gone without care because they

could not get in to see their PCP. The statement, “if I was bleeding - but not bleeding badly, I’d

probably wait a little bit” was echoed by another group member who said, “if it was a cut or rash,

unless it was really scary and went on for days, I would probably deal with it myself. I’m not a

medical person, but I’ve been around long enough.” These responses are examples where

decisions to delay or forego care for injuries with bleeding are being made by persons with no

medical background who make reference to “bleeding – but not bleeding badly” and not seeking

care unless the condition “was really scary or went on for days.” Another member responded that


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she “would first try massage, or acupressure, or acupuncture, or a chiropractor, or talk to friends

and naturalists,” noting that the staff at one local health food store was quite valuable as a source

of health care information. The group also shared a mutual respect for the local pharmacists, citing

that they are “very, very well-trained and extremely helpful.” One participant mentioned that if

she is prescribed a new medication, she will ask her doctor about it, “but then I go to the pharmacy,

and I ask them about it. And they’re very knowledgeable.”

Focus group members were asked if they, or someone they knew, had used the ED for non-

urgent problems because they could not be seen elsewhere. Several members gave the example of

a urinary tract infection (UTI) as a minor but time-sensitive illness for which they would seek care

in the ED if they were unable to see their PCP. One participant stated, however, that the wait for

care in the ED can be quite long, citing the experience of having a five-hour wait. The participants

repeatedly mentioned UTI, which is a medical diagnosis requiring urine culture, when they likely

meant symptoms of UTI, which can include dysuria, urinary frequency, urgency and hesitancy.

Patients are frequently unable to differentiate between symptoms of a generally benign illness and

those of a more serious or emergent nature.

Immediate Care is Meeting the Needs of Community Members Requiring Care for

Unexpected or Episodic Illness or Injury

The first question posed to the groups at the beginning of each session was “What would you

do if you had a minor medical complaint such as a rash, earache, cough, flu, or urinary complaint,

or if you had a minor injury like a sprain or strain, cut or other minor wound, or a back injury?”

The unanimous response: “Go to Immediate Care” referring to the Immediate Care Clinic-

affiliated with the local Critical Access Hospital (CAH). Specific comments were, “I would


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probably go to Immediate Care for that,” and “I wouldn’t even bother calling (my PCP), I’d just

go to Immediate Care.”

One participant polled her neighbors prior to coming to the focus group session and presented

a list of suggestions to improve health care in the community: Topping the list was the

recommendation that “Immediate Care should be available seven days a week from 8:00 a.m.

through 8:00 p.m.” Other group members commented that it would be helpful if immediate care

were available on weekends, even if only for half a day, specifically stating “it would certainly

help the community of people who have to work” and that you could “rely on kids getting sick on

the weekend.” A participant who had moved here from out of state expressed surprise when he

“found out there was nowhere to go on Saturday and Sunday for immediate care.”

Access to Routine Health Care Screening

All participants reported having received regular medical screening for hypertension,

diabetes, and depression as well as applicable screenings for cervical, colon, and breast cancers.

The reported barriers arose when these same patients sought care for unplanned medical problems.

Two members of one group noted that they were old enough that they were no longer candidates

for routine screening colonoscopies “because of perforation problems”. The youngest participant,

who was in the 30-44 year age bracket, stated that he was “about to be in the age bracket where

it’ll be worthwhile.” This comment is relevant in that it shows that the patient has been made

aware of screening guidelines. Participants shared that their providers had regularly discussed

with them the recommended clinical preventative services, as identified by Healthy People 2020

(n.d.a.). Contrary to the findings of the study by Allen et al. (2017), which examined barriers to

health care among adults with Medicaid insurance, the participants of these focus groups did not

forego preventative care because of barriers to primary care access.


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Specialty Services

Rural communities frequently lack specialty services that are common in more urban areas.

Participants were asked how they felt about their ability to get specialist care if needed. The

responses were numerous and emotional. A member of one group started the conversation by

stating “I feel like the specialist situation is a disaster, a complete disaster. We live so far from

anything else and we don’t have people here that are skilled enough or diverse enough to take care

of the needs of the young and of the aging population.” The fact that the next closest town with

more expansive medical specialty services is over two hours away was a special concern for one

participant who shared that “since I’m in my 80’s, I’ve gotten very anxious about what I feel is a

lack of healthcare here. And I even thought about leaving the area and going to another area where

I would be closer to a hospital that is solvent, and specialists, and better healthcare although I really

don’t want to leave the area.” This sentiment was shared by another member whose mother had a

heart condition and, although the woman “would have loved for her to move here … (but) the

medical care wasn’t good enough”. For the elderly, proximity to health care services was a

significant factor in where they chose to live.

The group discussed the fact that, currently, a cardiologist and a urologist travel to the area

two days each month to see patients in the community. Specialty services were once offered in

this rural area, but are no longer available. These services included pulmonology, dermatology,

gastroenterology, endocrinology, nephrology, and neurology. One participant, who moved to the

area within the past few years, stated that people in this area pay a little extra (by purchasing an

annual contract) for air medical transport insurance in the event they need to be transferred

emergently from the local critical access hospital to a hospital offering specialty services in another

town. Another group member mentioned that he had numerous friends who had been hospitalized


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out of the area because they needed specialty care and how this geographical separation is

detrimental to the recovery of the sick person who may be hours away from members of his or her

support system.

Discussion

Focus group participants in this study agreed that they want to be seen as whole and unique

individuals by providers they trust, i.e., providers who are permanent, rather than temporary,

members of the community and who will spend time listening to them. They understand that living

in a rural area presents a unique group of challenges to quality health care including a diminishing

number of providers and a lack of local specialty and consult services. While participants stated

they were able to access their PCP for routine and preventative care, they unanimously perceived

an inability to access primary health care services for sudden, or unexpected, episodic illness or

injury which, prior to the establishment of an immediate care clinic, led to foregone care, delayed

care, or seeking care in the emergency department for non-urgent problems. All focus group

participants stated that their health care needs for these medical conditions had been met by the

immediate care clinic.

The diminishing numbers of primary care providers is a problem in this, and other, rural

areas across the country. As providers retire, their patients are having to see new providers:

sometimes locums or temporary providers who are not as familiar with the patient on an individual

level. Section six of the National Clinical Guideline Centre (NCGC) 2012 publication on the

patient experience in adult national health services is titled “Knowing the patient as an individual.”

This section states that being recognized and treated as a unique individual is an important part of

the entire patient experience (NCGC, 2012).


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Most studies to date cite multiple barriers to primary healthcare access for routine

preventative medical care. Allen et al. (2017) specifically list: (a) personal issues such as family

responsibilities, work responsibilities, or lack of childcare availability, (b) problems with the

individual provider including language barriers, cultural or religious lack of understanding, lack

of trust in the provider, or an office environment which seemed “unwelcoming,” and (c) system-

specific factors related to coverage, financial barriers, inability to get an appointment, inability to

see the provider of choice, inability to be seen during regular office hours, and not being familiar

with the location of the office. All focus group participants in this study reported having a primary

care provider whom they saw on a regular basis for preventative care and chronic medical

problems. All participants reported having had clinical preventive services, including screening

for the prevention or early detection and treatment of colorectal cancer, breast cancer, and cervical

cancer, which are leading health indicators identified by Healthy People 2020 (n.d.) performed

where appropriate for age and gender. It was when they sought care for an unplanned or episodic

illness or injury that the barriers to care became apparent. Every member of the focus groups

reported that, prior to the existence of the immediate care clinic, they would have experienced

delays in care for unplanned illnesses or injuries, citing delays of up to three weeks.

None of the respondents answered that they had experienced personal issues as barriers to

care, although one participant noted her daughter works all week and that if she takes time off for

a medical appointment “she loses money when she has to see a doctor and that’s not right.” The

same woman also stated, “if you’re talking to single parents who are working full-time and raising

children, they might lose a job if they’re not on the job from 8:00 – 5:00 every day, or they might

not have a car or money for gas. So there are circumstances, I think, that would affect other people

differently.” A 2008 study by the National Opinion Research Center at the University of Chicago


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found that 16% of workers in low-wage jobs reported that they, or a family member, had been

fired, suspended, punished, or threatened with firing for missing work because of personal or

family illness (Smith, 2008).

One participant questioned the practice of parents taking their children to the ED for minor

problems on the weekends. However, she quickly acknowledged that the only other option was to

wait until Monday and run the risk of not being able to get an appointment with the PCP for another

two weeks. These reports are consistent with the findings of a study examining ED use for non-

urgent complaints resulting from an inability to access primary care published in the American

Journal of Medical Quality. The study concluded that both publicly and privately insured patients

utilized the ED for minor complaints because they were unable to get an appointment with their

provider, they had not been able to establish care with a PCP, or they had difficulty making time

for an appointment during traditional business hours (Hefner et al., 2015). Uninsured patients

utilizing the ED instead of a PCP had additional barriers related to financial, insurance, or

transportation factors.

At the provider level, no discrimination or cultural issues were identified by either group and

members specifically stated that they had no knowledge of anyone in the area experiencing

discrimination or a lack of cultural respect. However, lack of trust in the provider was cited by

half of the group members and their responses indicated that the 15-minute appointment was the

reason for this mistrust. They did not feel that 15 minutes was enough time for a provider to

properly evaluate and treat them. One patient, who was not a member of the focus groups,

presented to Immediate Care for care of a large second degree burn to her forearm. She stated that

she had seen her private physician earlier in the day for a well-women exam. At the end of her

30-minute visit, she attempted to show her PCP the burn and was reportedly told that her visit had


146

already “run over-time” and she would need to “go to Immediate Care” to have the burn looked

at. In her visit to the immediate care clinic, the provider spent time getting the history, examining

the burn, performing wound care, instructing the patient on home wound care, providing her with

the supplies needed for wound care and a prescription for a topical antimicrobial medication,

educating her on what to watch for in the event of complications like infection, and giving her

follow up instructions.

The Immediate Care clinic profiled in this study is meeting the needs of community members

seeking care for unplanned illness or injury, regardless of their insurance or payment type and

regardless of their regular PCP assignment. This model of care offers same-day care, with no

appointment necessary, for patients experiencing acute, non-emergent medical problems and

minor injuries when their PCP is unavailable or if the patient has no PCP. The care provided at an

immediate care clinic has been compared to that received from a PCP, but more accessible and

convenient for the patient; unlike an urgent care clinic which is generally equipped to handle non-

life-threatening emergencies along with basic health care services (George Washington Medical

Faculty Associates, 2014).

Strengths and Limitations

The most notable strength of the study lies in the analysis of the qualitative content of the

focus group sessions which not only echoed many of the barriers to care noted in the literature

review, but also identified immediate care as a real solution to the problem of access to healthcare

for episodic complaints. Focus groups proved to be an effective method to explore the participants’

perceptions of barriers to health care access as it allowed the group members to share their own

experiences and build on shared experiences. The strength of the study is further reinforced by

the fact that the researcher is also the lead health care provider in the immediate care clinic and is


147

involved in direct patient care 32 hours per week, allowing her to integrate the findings of

published studies with actual practice.

The small sample size, combined with the homogeneity of participants with respect to age,

race, ethnicity, and insurance type, was the most notable limitation of the study. Although the

participants were engaged and enthusiastic, eight is minimal for qualitative research using focus

groups (Stewart & Shamdasani, 2015). Additional data may have been gathered from younger

participants, participants from more diverse racial and ethnic backgrounds, and more participants

who were employed on a full-time basis and faced the challenge of making health care

appointments during traditional work hours.

Nursing Implications

Advanced practice registered nurses (APRN), especially those with family practice and

emergency department experience, are in a prime position to provide safe, timely, effective,

efficient, equitable, and patient-centered care to community members who would otherwise not

receive it. The immediate care model is an easily implemented and cost-effective strategy to

provide this care. The APRN is knowledgeable in evidence-based practice and has the clinical

expertise and experience to provide care based on best practice. In addition to critical thinking,

clinical judgement, and clinical decision-making skills, the experienced APRN has the additional

qualities, developed through nursing practice, of strong communications skills with patients and

families as well as other health care professionals.

As of 2019 there are 34 CAHs in the state of California and 1,348 in the entire United States

(RHIhub, n.d.a.). Critical Access Hospital EDs across the country struggle with surges in patient

flow. In EDs with single physician coverage, one critically ill patient may overwhelm all available

resources (e.g., physician, nursing, respiratory therapy, diagnostic imaging, laboratory) for


148

prolonged periods of time which results in low-acuity patients having extended wait times (Welch,

2017). In facilities where the physical plant cannot accommodate a fast-track or low-acuity

throughput process, these patients will continue to wait - leading to a delay in care or, if they are

unable to keep waiting, foregone care.

The Immediate Care clinic referred to by focus group participants is located within a suite of

outpatient clinical offices on the property of a 25-bed CAH, but physically separate from the

hospital itself. Hospital laboratory and diagnostic imaging services are available to immediate

care patients. The immediate care practice is open weekdays from 9:00 a.m. until 6:00 p.m. and

is closed for one hour at lunch. One APRN sees an average of 20 patients per day. One medical

assistant from the outpatient clinic is assigned to the immediate care provider and registration staff

is shared with the other outpatient clinics. The four patient exam rooms are in one of the three

office suites that also houses seven primary care providers.

Certain new models of ambulatory care including free-standing urgent care clinics, retail

clinics, and electronic visit websites have been seen as threats in continuity of care, a disruptive

innovation which may erode the relationship between the patient and the primary care provider

(Ladapo & Chokski, 2014). Services provided at this immediate care clinic, frequently not

provided in other convenient care or urgent care settings, were developed to enhance

communication between health care team members and to improve patient outcomes. These

services make this clinic stand out when compared to other immediate or convenient care clinics.

For the patient reporting that he or she is already established with a PCP, a copy of the encounter

document is faxed to that provider. For patients reporting that they do not have a PCP, they will

be given a list of area providers or, if they prefer, an appointment with a PCP in the same practice

will be made during the visit. If a patient does not have health insurance, an access coordinator


149

will attempt to see if the patient is eligible for any of the public insurance plans and assist with

paperwork. If the APRN determines that a patient would benefit from specialty consultation, such

as orthopedic surgery or otolaryngology, the referral can be made during the visit rather than

sending the patient back to the PCP for referral.

Conclusions

Physician supply and demand studies have projected that, by the year 2025, there may be a

shortage of as many as 31,000 adult primary care providers in the U.S. (Long et al., 2016). Reasons

for this projected shortage include the fact that: fewer medical residents are planning to go into

primary care or internal medicine, opting instead to pursue specialty practices (Long et al., 2016),

there is a shortage of healthcare providers through attrition of practicing providers, and it is

difficult to recruit and retain new providers to rural areas (Ewing & Hinkley, 2013). Permanent

solutions to the problem will not come quickly.

During the Obama administration, the U.S. Department of Health and Human Services,

recognizing the impending shortage of PCPs in rural areas, was tasked with improving recruitment

and retention of health care providers in rural areas through the “Improving Rural Health Care

Initiative.” Several programs oriented toward this goal were developed by the Health Resources

and Services Administration (U.S. Department of Health & Human Services [U.S.DHHS], n.d.).

Funding opportunities like the Primary Care Training and Enhancement Program have become

available to hospitals in rural communities and, while these programs may ultimately benefit the

rural community, these benefits are not likely to be realized for many years. Moreover, many rural

hospitals and clinics do not have staff with the grant-writing expertise of experience to apply for

these programs (U.S.DHHS, n.d.).


150

Recruitment and retention of health care providers to rural communities can be further

compounded by perceptions of the providers themselves. Medical residents have cited

professional isolation, lower salaries, the challenges of primary care medicine, and concern for

lack of ancillary mental health and social services support in rural communities (Long et al., 2016).

In a study of primary care medicine residents, a lower salary was one factor that the residents had

initially felt was a fair compromise for the benefit of living in a rural area, but by the end of the

study, the residents felt that the lower salaries, coupled with the negative elements of rural practice

including stress, personal and professional isolation, and fear of burnout expressed by their

mentors deterred them from pursuing practices in rural areas (Long et al., 2016). A 2013 study by

Farmer, Prior, and Taylor used a capitals framework to link rural health services to community

sustainability. Economic, social and human capitals were analyzed, using measurable indicators,

and applied to individuals and institutions to show the added-value contributions of health services.

The contributions included jobs for educated, knowledgeable, and skilled community members, a

location for people to become skilled, personal and institutional consumption of locally produced

goods and services including schools and real estate, attracting new community members while

retaining older residents, and helping to maintain a diverse local population (Farmer et al., 2013).

The use of telemedicine should be considered and may be attractive to the provider with

concerns about lack of professional support. Other factors include lack of available or affordable

housing, few employment opportunities for spouses or partners, limited school options for

children, and a lack of cultural outlets (Cohen, 1998). Some of these factors, such as suitable

housing, can be addressed with community leaders while other factors will remain deterrents to

providers and their families considering relocation to a rural area.


151

The 20% of the U.S. population living in rural communities who are being cared for by only

10% of physicians (Hospitals & Health Networks, 2016) need options when they experience minor

illness or injuries. Delayed care, foregone care, and use of the ED are not efficient or equitable

solutions. Prompt, competent, evidence-based treatment provided in a timely manner is a solution

and immediate care clinics like the one profiled in this study can provide that care: in many cases

with resources that are already available. In the words of community member R. L. Cizek

(personal communication, April 17, 2019), “Immediate Care is the best thing to happen to health

care in this town.”

References

Agency for Healthcare Research and Quality, (n.d.). The six domains of health care quality.

Retrieved from https://www.ahrq.gov/talkingquality/measures/six-domains.html

Allen, E. M., Call, K. T., Beebe, T. J., McAlpine, D. D., & Johnson, P. J. (2017). Barriers to care

and health care utilization among the publicly insured. Medical Care, 55, 207-214.

https://doi.org/10.1097/MLR.0000000000000644

Centers for Disease Control and Prevention, National Centers for Health Statistics (n.d.) NCHS

Urban-Rural Classification Schemes for Counties. Retrieved from https://www.cdc.gov/

nchs/data_access/urban_rural.htm

Cohen, J.J. (1998). Why don’t doctors go where they’re needed? Retrieved from http://www.rural

medicaleducation.org/why_docs_dont.htm

Douthit, N., Kiv, S., Dwolatzky, T., & Biswas, S. (2016). Exposing some important barriers to

health care access in the rural USA. Public Health 126, 611-620. https://doi.org/

10.1016/j.puhe.2015.04.001


152

Ewing, J., & Hinkley, K. N. (2013). Meeting the primary care needs of rural America: Examining

the role of non-physician providers. Retrieved from http://www.ncsl.org/documents/health/

RuralBrief313.pdf

Farmer, J., Prior, M., & Taylor, J. (2013). A theory of how rural health services contribute to

community sustainability. Social Science & Medicine, 75, 1903-1911. https://doi.org/

10.1016/j.socscimed.2012.06.035

Ford, J.A., Turley, R., Porter, T., Shakespeare, T., Wong, G., Jones, A.P., & Steel, N. (2018).

Access to primary care for socio-economically disadvantaged older people in rural areas: A

qualitative study. Public Library of Science, 13(3). https://doi.org/10.1371/journal.pone

.0193952

George Washington Medical Faculty Associates. (2014). Urgent vs. immediate care: Is there a

difference? Retrieved from https://gwdocsipc.com/urgent-vs-immediate-care-is-there-a-

difference/

Healthy People 2020 [Internet]. (n.d.). Clinical preventative services. Washington, DC: U.S.

Department of Health and Human Services, Office of Disease Prevention and Health

Promotion. Retrieved from https://www.healthypeople.gov/2020/leading-health-

indicators/2020-lhi-topics/Clinical-Preventive-Services

Hefner, J.L., Wexler, R., & McAlearney, A.S. (2015). Primary care access barriers as reported by

non-urgent emergency department users: Implications for the US primary care infrastructure.

American Journal of Medical Quality, 30, 135-140. https://doi.org/10.1177/1062860614521

278

Hing, E. & Hsaio, C. (2014). State variability in supply of office-based primary care providers:

United States, 2012. NCHS Data Brief 151. Retrieved from https://www.ruralhealthweb.org/


153

NRHA/media/Emerge_NRHA/PDFs/db151.pdf

Hospitals & Health Networks. (2016, January 21). Rural physician shortage demands innovative

solutions. Retrieved from https://www.hhnmag.com/articles/6881-rural-physician-shortage-

demands-innovative-solutions

Hsieh, H. & Shannon, S.E. (2005). Three approaches to qualitative content analysis. Qualitative

Health Research, 15, 1277-1288. https://doi.org/10.1177/1049732305276687

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century.

Washington, D.C.: National Academy Press; 2001.

Ladapo, J. & Chokski, D. (2014). Continuity of care for chronic conditions: Threats, opportunities,

and policy. Retrieved from https://www.healthaffairs.org/do/10.1377/hblog20141118.

042672/full/

Leight, S. B. (2003). The application of a vulnerable populations conceptual model to rural health.

Public Health Nursing, 20, 440-448. Retrieved from https://doi.org/10.1046/j.1525-

1446.2003.20604.x/full

Long, T., Chaiyachati, K., Bosu, O., Sirdar, S., Richards, B., Garg, M., … Huot, S. (2016). Why

aren’t more primary care residents going into primary care? A qualitative study. Journal of

Internal Medicine, 31, 1452-1459. https://doi.org/10.1007/s11606-016-3825-9

Mareno, N. (2016). Applying middle-range concepts and theories to the care of vulnerable

populations. In M. deChesnay & B. A. Anderson (Eds.), Caring for the vulnerable:

Perspectives in nursing theory, practice, and research (4th ed., pp. 117-139). New York,

NY: Jones & Bartlett Learning.


154

Mortensen, K. (2014). Access to primary and specialty care and emergency department utilization

of Medicaid enrollees needing specialty care. Journal of Health Care for the Poor and

Underserved, 25, 801-813. https://doi.org/10.1353/hpu.2014.0097

Moy, E., Garcia, M.C., Bastien, B., Rossen, L.M., Ingram, D.D., Faul, M. … Iademarco, E.F.

(2017). Leading causes of death in nonmetropolitan and metropolitan areas: United States,

1999-2014. MMWR Surveillance Summary 2017, 66(SS-1). Retrieved from http://dx.doi.org/

10.15585/mmwr.ss6601a1

National Clinical Guideline Centre. (2012) Patient experience in adult NHS services: Improving

the experience of care for people using adult NHS services. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK115230/pdf/Bookshelf_NBK115230.pdf

Nyamathi, A., Koniak-Griffin, D., & Greengold, B. A. (2007). Development of nursing theory and

science in vulnerable populations research. Annual Review of Nursing Research, 25, 3-25.

https://doi.org/10.1891/0739-6686.25.1.3

Rural Health Information Hub. (n.d.a.). Healthcare access in rural communities. Retrieved from

https://www.ruralhealthinfo.org/topics/healthcare-access

Rural Health Information Hub. (n.d.b.). Am I rural?. Retrieved from https://www.ruralhealthinfo

.org/am-i-rural/

Smith, T. (2008). Paid sick days: A basic labor standard for the 21st century. Retrieved from

http://www.norc.org/PDFs/publications/PaidSickDaysReport.pdf

Stewart, D. W., & Shamdasani, P. N. (2015). Analyzing focus group data. In D. W. Stewart (Ed.),

Focus Groups: Theory and Practice (3rd ed., 115-140). Thousand Oaks, CA: Sage.

United States Department of Health & Human Services. (n.d.). Federal Office of Rural Health

Policy. Retrieved from https://www.hrsa.gov/rural-health/index.html


155

United States Health Policy Gateway. (n.d.). ACA and physician shortage. Retrieved from

http://ushealthpolicygateway.com/vii-key-policy-issues-regulation-and-reform/patient-

protection-and-affordable-care-act-ppaca/ppaca-research-and-analysis/ppaca-impact-on-

access/impact-on-access-to-care/physician-shortage/

Welch, S. (2017). Patient flow improvements to boost efficiency in small emergency departments.

Retrieved from https://www.acepnow.com/article/patient-flow-improvements-boost-

efficiency-small-emergency-departments

Zip-codes.com. (n.d.). Mendocino County, CA ZIP codes. Retrieved from https://www.zip-

codes.com/county/ca-mendocino.asp

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